HomeMy WebLinkAboutCentral St. #260 - 5/6/2004c-�
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MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name L-e s I I e--
Address: _? to,0 L-C Vt iYC %1 t" wlCsl 'AT
alephone S®�
Location:
Registered
Well Driller: Pct u Q �&V� MO hS MA Lie #
Address: P .C) S t a fC'r S� 1 4 % 0 d 9'1 G
TYPE OF WELL:
_ Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
_ Industrial/Commercial Potable (for human consumption, including food processing)
_ Industrial/Commercial Auxiliary (for manufacturing, etc.)
_ Agricultural (for irrigation of land in the business of agriculture)
Fee: . Domestic $10.00 _ Industrial/Commercial $100.00 N/C Agricultural
Date: S LIt, 0 Ll Applicant Signatureju Lk A 1
The above application
following use at Z
PERMIT TO DRILL WELL
and permission is granlcd-td drill a well for the
Domestic Potable (for household use)
t_=-' Domestic Auxiliary (for watering, pools, etc.)
_ Industrial/Commercial Potable (for human consumption, including food processing)
_ hidustrial/Commercial Auxiliary (for manufacturing, etc.)
_ Agricultural (for irrigation of land in the business of agriculture)
Date: �� c Approved by:
-1 birAhe Board of Health
NOTE. Electrical permit required; underground cable trench must be inspected.
Upon Installation of well, call Department of Public Works office at
261-7330 to be added to well list